MEDICARE: KENYAS COUNSELING AND CONSULTING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1104526144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENYAS COUNSELING AND CONSULTING

Provider Business Mailing Address
First Line	:	281 HARRELL MILL RD
Second Line	:
City	:	CLIMAX
State	:	GA
Zip	:	39834-2778
Country	:	US
Telephone Number	:	229-220-5306
Fax Number	:

Provider Business Practice Location Address
First Line	:	281 HARRELL MILL RD
Second Line	:
City	:	CLIMAX
State	:	GA
Zip	:	39834-2778
Country	:	US
Telephone Number	:	229-220-5306
Fax Number	:	888-493-0450

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	REVON MILLER
Credential	:	MS, LPC, LMHC, CRC,
Telephone Number	:	229-220-5306

Provider Enumeration Date	:	03/08/2023
Last Update Date	:	03/08/2023

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